Order Form
211 East Chic
Chicago, Illino
If you wish to use the Order Planner as a mail-in order
form, please fill out the following information.
BILLING & SHIPPING INfORMATION
ADA NUMBER
NAME
ADDRESS
CITY
STATE
zIP
EMAIL
DAYTIME PHONE NUMBER
PAYMENT METHOD
Payment or credit card information must accompany all orders. Call 800.947.4746 for
your order total. Checks are only accepted via mail orders. Make checks payable to:
American Dental Association.
[ ] Check
[ ] Visa
[ ] MasterCard
[ ] American Express
CREDIT CARD NUMBER
EXPIRATION DATE
SIGNATURE
The ADA VISA Signature Card
The ADA VISA
• Earn 5x points on every
Signature Cardpurchase.
ADA
• Enhanced rewards, benefits
and perks exclusively for
ADA members.
To apply: usbank.com/ADAVisa or call 888.327.2267 x80023
